Yearly Archives: 2013

David J. Wright, MA., MSW
WKPIC Doctoral Intern

 

Schizophrenia causes pain, enormous suffering, and significant physical and emotional distress to the individual, but also to the primary caretakers. Recent headline news has focused on emotional stories that involved mental illness and psychosis. These stories are tangible, and the consequences of untreated mental illness continue to hurt members of our society. Increased understanding of this devastating disorder is essential to stopping this pain and damage.

 

In their article, the authors examine specific risk factors (i.e., familial liability and perinatal problems) that are often overlooked during young childhood and adolescent stages of development.  Family, twin, and adoption studies strongly suggest that genetic transmission accounts for most of the familial aggregation in schizophrenia. The risk of contracting the  disorder is about 10 times higher if a first-degree relative is ill, and decreases from close to more distant relatives. The authors review numerous studies about risk factors, which indicate that many people who develop schizophrenia are exposed to a variety of stressful perinatal events such as extreme maternal stress, maternal antenatal depression, prenatal exposure to influenza, living in an urban area, obstetrical complications, poor maternal nutrition, and famine, just to name a few.

 

The authors further present two models for the onset of psychosis; The Vulnerability Model and The Hybrid Model. The Vulnerability model addresses the diathesis-stress model, which explains individual behavior as a predisposition or vulnerability together with stress from life experiences. It can take the form of genetic, psychological, biological, or situational, environmental factors.  The Hybrid/interactive model is more or less an equilibrium model in which vulnerable individuals have possibilities to move in any direction between an asymptomatic and symptomatic state.

 

Salokangas & McGlashan (2008) take a proactive position about combating the acceleration of prodromal symptoms, which is potentially important for early intervention and comprehending the psychotic process. In clinical practice, a prodrome is an early symptom or set of symptoms that might indicate the start of psychotic-like experiences. The symptom profile of prodromes is extremely variable. The most frequent features include disturbances of attention or inability to concentrate, apathy or loss of drive, depression, sleep disturbances, anxiety, social withdrawal, suspiciousness, deterioration in school, work or other functioning, and anger coupled with irritability. Clearly, these are non-specific to schizophrenia and are very often seen, for example, in the early phases of depression. The prodrome to schizophrenia usually begins with additional nonspecific, neurotic-like symptoms, followed by more specific pre-psychotic symptoms, eventually leading to frank psychosis. The awareness of, early detection of, and aggressive treatment of these symptoms may prevent patients and families and entire communities from descending into the pandemonium of a completed psychotic process.

 

However, the key question remains: What interventions are available to patients at risk of psychosis? The authors address neuroleptic treatment, cognitive psychotherapy, and integrated treatment to define standards of care and contribute to best practices.

 

This article was useful to me at an internship level, in better understanding the risk factors associated with the evolution of schizophrenia, and the importance of early intervention into an evolving psychotic process.

 

References

 

Salokangas, R.K.R., & McGlashan ,T.H. (2008). Early detection and intervention of
psychosis. A review. Nord J Psychiatry 2008;62:92. Oslo. ISSN 0803-9488.

 

The Prodromal Phase of First-episode Psychosis: Past and Current Conceptualizations.  Retrieved from http://www.mentalhealth.com/mag1/scz/sb-prod.html.

 

 

 

 

So, like the internship classes of 1980-1982 (DSM-III) and 1994-1996 (DSM-IV), you’re the “tweeners.” You’re one of those unfortunate few students finishing school and hitting the licensing exam just as we’re switching to a new diagnostic manual. This time around, the madness is heightened by the fact that many, many settings have yet to determine if they will embrace DSM-V, or shift operations to ICD-10/11. Most will be taking full advantage of the two-year grace period before changing systems. Because of this, you face the very real possibility that you’ll train under one system, but have to tackle taking an Examination for the Professional Practice in Psychology (EPPP)  that focuses on a radically different diagnostic framework.

 

Stop screaming.

 

It’s do-able.

 

 

And here’s how, in two or three easy steps. Okay, maybe not easy, but not impossible, either!

 

First, remember how smart you are. You didn’t go to graduate school and finish all that work because you have difficulty learning new information. Remember those first few classes? You knew *nothing*, and now look how far you’ve come. Studying for the licensing exam, no matter which diagnostic system you use, is no different than all those exams and papers you’ve already conquered. Scarier, sure. But really, no different. You’ve got this.

 

Second, for those of you on internship right now, or who already have your Master’s Degree, you can take the examination before you finish internship, or just as you do. If you get in before the July 31, 2014 change date, you’ll miss all of the insanity and answer questions based on the DSM-IV-TR only. Problem solved. If you can pull this off before March, 2014, you’ll also save money, as the cost of the EPPP is going up, too. WKPIC has encouraged our current interns to consider this option, and we’re willing to assist with study time and quizzing as needed. Also, Dr. Kuszak just took the test on October 1, so she knows–she really, really knows–the angst involved and the preparation needed. She feels your pain! (She did great, by the way, YAY DR. K!!).

 

Finally, if taking the exam before the change date is not an option for you, we suggest that you quickly secure a copy of the DSM-V, or if you’re a WKPIC intern, use the student copy available in the state hospital intern office. Every time you render a diagnosis in DSM-IV-TR or ICD-10/11, take the extra 5-10 minutes to look up and write down the terminology used by the DSM-V as well. Discuss points of confusion with your supervisors. Trust us, we’ll be learning, too. These extra minutes could pay huge dividends for you, come examination time. Consider attending a continuing education seminar related to DSM-V, or viewing one by webinar as well. Your sites may have materials like this already available (we do, on our state hospital intranet), so be sure to ask about this possibility.

 

Alicia Taylor, Psy.D., WKPIC Internship Director
Susan Vaught, Ph.D., WKPIC Training Director

 

 

 

Keep calm and carry on. . .

 

Relaxation skills are important for all clinicians and clients. A great resource for guided relaxation exercises is Meditation Oasis. Mary and Richard Maddux have created a great online resource at the Meditation Oasis. On the site, you can find can find dozens of audio files, as well as “how to” guides for different types of relaxation and meditation. This resource is free and the audio files are available on the website and as an iTunes podcast.

 

 

 

 

Danielle M. McNeill, M.S., M.A.
WKPIC Doctoral Intern

 

 

Vanderbilt University’s Kennedy Center is in the process of adapting and augmenting an amazing Canadian toolkit to help practitioners better serve people who have intellectual or developmental disabilities. VUKC’s new toolkit website won’t officially be live and launched until February, 2014, but it is already packed full of extremely useful and well organized information. Interns and residents may find this site to be a life-saver as they learn to navigate care provision for this underserved group.

 

Susan R. Vaught, Ph.D.
WKPIC Training Director

 

 

 

 

As treating clinicians, we are interested in what makes a great initial interview with a client. We want the client to feel comfortable with us enough for her to share her most difficult memories and reveal aspects about herself that she is most ashamed of. We want the client to be honest and, as much as possible, not feel uncomfortable when she is honest.

 

If the client is a potential therapy client, we want her to feel confident enough in us to return for the next session. We need the client to feel that treatment is worthwhile and will ultimately help her. Thus, Carlat (2005) explains in his book, The Psychiatric Interview, the larger goal in mind during the diagnostic interview is treatment. If you do not keep this goal in mind during the first interview, your client may never return for the second visit and “your finely wrought DSM-IV-TR diagnosis will end up languishing in a chart in a file room.”

 

Studies have shown that up to 50% of clients drop out before the fourth session of treatment and many never return after their first appointment. There are many reasons for treatment dropout. Some clients do not return because they have formed poor alliances with their clinicians, some because they weren’t really interested in treatment in the first place, and others because the initial interview alone helped them enough to get them through their stressors. Thus, much more than diagnosis should occur during the first interview.

 

Alliance building, morale boosting, and treatment negotiating are all extremely important. You should establish a therapeutic alliance as you learn about your client. The very act of questioning is an alliance builder; people tend to like people who are warmly curious about them. As you ask questions, you formulate possible diagnoses, and thinking through the diagnoses leads naturally to the process of negotiating a treatment plan. These aspects are all important in the initial interview and can help to make the client feel more comfortable and return for further treatment.

 

Reference: Carlat, D.J. (2005). The psychiatric interview: A practical guide. 2^nd ed. Philadelphia, PA: Lippincott Williams & Wilkins.

 

Cindy A. Geil, M.A.
WKPIC Doctoral Intern